Reconstruction of Anterior Nasal Septum: Back-to-Back Autogenous Ear Cartilage Graft

The Laryngoscope Lippincott Williams & Wilkins, Inc. © 2004 The American Laryngological, Rhinological and Otological Society, Inc. Reconstruction of Anterior Nasal Septum: Back-to-Back Autogenous Ear Cartilage Graft Wolfgang Pirsig, MD; Eugene B. Kern, MD; Thomas Verse, MD Objectives/Hypothesis: The ideal material for reconstructing the nasal septum in the deficient nose has not been found. Since 1986, the authors have used autogenous cartilage from the cavum conchae to successfully correct the anterior septum and the associated cartilaginous saddle. The long-term results in 26 patients with a destroyed septum and a saddle nose are reported. Study Design: Retrospective study. Methods: The mean age of the patients at surgery was 40.2 years, and the mean number of previous nasal procedures was 1.6. Because 11 patients had septal perforations and insufficient septal cartilage or bone, ear cartilage grafts from the cavum conchae were harvested through an anterolateral approach. A special incision was used to divide the concave ear cartilage while preserving the posterior perichondrium. This produced a stable, balanced back-to-back graft. The graft was 2.5 to 3 cm long, long enough to allow reconstruction of the anterior septum and to correct part of the saddle nose deformity. The rest of the conchal cartilage was used to fill the remaining cartilaginous saddle. Follow-up investigations included photographs and visual analogue scales of the patients’ symptoms and satisfaction. Results: After a mean interval of 36.7 ⴞ 22.3 months, the back-to-back grafts showed no macroscopic signs of resorption. Graft position and shape remained intact after transplantation. All noses were adequately projected and mobile. All patients but one were satisfied with the functional and esthetic result. With a score of 4 representing the level of satisfaction as “very good,” the mean score of the patients was 3.2 ⴞ 0.79. The saddle of the nose completely disappeared in 65.4% of patients, was minimally visible in 23.1%, and was slightly present in 11.5%. Nasal breathing improved Presented in part as a Poster at the Annual Meeting of the German Society of Otorhinolaryngology—Head and Neck Surgery, Aachen, Germany, May 12–15, 1999. From the Otorhinolaryngology Clinic (W.P.), University of Ulm, Ulm, Germany; the Department of Otorhinolaryngology (E.B.K.), Mayo Clinic, Rochester, Minnesota, U.S.A.; and the University Otorhinolaryngology Clinic (T.V.), Mannheim, Germany. Copyright © 2003 Mayo Foundation. Editor’s Note: This Manuscript was accepted for publication October 21, 2003. Send Correspondence to Wolfgang Pirsig, MD, Universitäts-HNOKlinik, Prittwitzstrassen 43, D-89075 Ulm, Germany. Laryngoscope 114: April 2004 considerably in 21 patients, remained the same in 4 patients, and worsened in 1 patient. The mean score of all patients for nasal breathing was 7.3 ⴞ 1.87 on a visual analogue scale of 0 to 10, with 10 representing satisfaction as “very good”. Conclusion: The back-toback autogenous ear cartilage graft is a viable, stable, and balanced graft for functional and aesthetic reconstruction of the anterior nasal septum and cartilaginous saddle deformity in patients with a severely traumatized and deficient septum. Key Words: Autogenous ear cartilage, saddle nose, septal reconstruction, septum perforation. Laryngoscope, 114:627– 638, 2004 INTRODUCTION The destruction of the anterior nasal septum resulting from surgical or nonsurgical trauma, including septal abscess, frequently produces sagging or saddling of the cartilaginous nasal dorsum, with widening of the angles of the nasal valve. Thus, both functional and aesthetic aspects have to be considered when reconstructing the anterior septum. Autogenous and allogenous transplants and xenogenous implants have been used to provide the cartilaginous nose with more or less satisfying projection and protection.1–15 In the present report, we present the functional and aesthetic long-term results of anterior septal reconstruction with a straight and balanced back-to-back autogenous ear cartilage graft according to a technique that was created by one of the authors (W.P.) in 1986. PATIENTS AND METHODS The study group included 26 consecutive patients (7 women and 19 men) who had nasal surgery at the Otorhinolaryngology Clinic, Ulm University (Ulm, Germany) between 1993 and 1998 (Table I). The mean age of the patients at surgery was 40.2 years. The mean age of the women was 39.4 years (age range, 17– 67 y), and of the men, 40.5 years (age range, 8 –72 y). In all 26 patients, the anterior septum and part of the posterior septum were destroyed to the extent that sufficient autogenous material could not be harvested from the remnant septum for septal reconstruction. All patients had a severe saddle deformity in the nasal dorsum as a result of previous surgical or nonsurgical trauma (or both). Pirsig et al.: Nasal Septum Reconstruction 627 TABLE I. Outcome in 26 Patients Who Had Reconstruction of Anterior Nasal Septum by Back-to-Back Autogenous Ear Cartilage Graft.* Patient No. Sex Age (y) FollowUp (mo) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Mean SD of mean Maximum Minimum F M M M M F M F M M M M M F M M M M M M M M M F F F 28 29 39 31 48 51 53 47 72 22 8 55 29 36 21 57 37 49 33 53 50 31 45 66 17 39 40.2 15.00 72 8 70 38 59 75 29 27 65 40 7 54 18 63 12 50 17 38 88 6 18 28 28 9 12 35 37 32 36.7 22.29 88 6 No. of Previous Operations Nasal Breathing† Olfaction† 1 1§ 1 1§ 2 1 1 3 3 1 0 1 2 4§ 1§ 3§ 2 1§ 2§ 2§ 0 3 1 1§ 2§ 1§ 1.6 0.96 3 0 8 (⫹) 7.5 (⫹) 6.5㛳 8.5 (⫹) 3 (⫹) 9 (⫹) 10 (⫹) 8 (⫹) 6 (⫹) 10 (⫹) 7.5 (⫹) 5㛳 7 (⫹) 8㛳 7 (⫹) 10 (⫹) 5 (⫹) 4 (⫺) 8 (⫹) 6 (⫹) 10 (⫹) 7 (⫹) 7㛳 10 (⫹) 7 (⫹) 5.5 (⫹) 7.3 1.87 10 3 10 (⫹) 5㛳 4㛳 7.5 (⫹) 9㛳 9 (⫹) 10 (⫹) 8㛳 9 (⫹) 9 (⫹) 8.5㛳 10㛳 8 (⫹) 9㛳 8 (⫹) 7㛳 7 (⫹) 6㛳 7 (⫹) 9㛳 10㛳 10㛳 8㛳 5㛳 10㛳 10㛳 8.2 1.69 10 4 Saddle (Postoperative) CC CC CC SP MV CC MV MV CC CC CC SP CC CC CC MV MV CC CC CC CC CC SP CC MV CC Satisfaction‡ 4 3 3 3 2.5 4 4 4 3 4 3 2 3 4 2 3 3 2.5 4 4 4 3 1 4 4 3 3.2 0.79 4 1 *Appearance was considered improved for all patients except patients 12 and 23, who had no change. † Visual analogue scale from 0 (none) to 10 (maximally improved). ‡ Visual analogue scale from 0 to 4 (0 ⫽ no, 1 ⫽ poor, 2 ⫽ moderate, 3 ⫽ good, and 4 ⫽ very good). § Pre-existing septal perforation. 㛳 No change. CC, completely corrected; MV, minimally visible; SP, slightly present; ⫹, improved; ⫺, worse. Surgical Technique In all patients, an entire cymba-cavum concha complex was harvested from the external ear by an anterolateral approach through an incision several millimeters inside the contour line along the posterior conchal wall and inferior crus.16 A layer of perichondrium and soft tissue was preserved on the posterior surface of the graft. Cutting only the cartilage enables back-toback folding of both halves, creating a stable caudal end graft (Fig. 1). The bean-shaped transplant was divided into a larger, elliptical piece and a smaller, half-elliptical piece (Fig. 1). The small piece was used in one or more layers to fill the saddle of the nasal dorsum. The larger piece was incised medially on its concave surface without cutting through the posterior perichondrium (Fig. 1). Both halves were tipped back after a 90° rotation to form a back-to-back graft joined by the common perichondrium (Fig. 1). Two 4-0 polyglactin 910 (Vicryl) mattress sutures, which were later used as guiding sutures, united this straight and balanced Laryngoscope 114: April 2004 628 graft, which usually was 2.5 to 3.0 cm long (Fig. 1). In some cases, the ends of the graft were not included in the sutures, allowing for some curling because of their intrinsic elasticity similar to the feet of the medial crura. This allowed better fixation to the anterior nasal spine and to the remnants of the caudal ends of the upper lateral cartilage. The graft was placed in the prepared columella and anterior septal pocket in front or on the anterior nasal spine between the feet of the medial crura through a hemitransfixion incision or external approach. Cranially, it was sutured to the remnants of the septum in the valve area. The graft was in an oblique position between the nasal spine and nasal valve, pushing the valve cranially (Fig. 1). Mattress sutures through the skin of the columella and anterior septum generally were not necessary to hold the graft in place. In most of our patients, one part of the saddle could be corrected by the backto-back graft. The remaining saddle was filled with the remnants of the ear graft, which can be introduced in one to three layers Pirsig et al.: Nasal Septum Reconstruction Fig. 1. (A) Principle of back-to-back cartilage graft. (B) The cymba-cavum concha complex is harvested through anterolateral approach. (C) The larger part of the graft is incised without cutting through posterior perichondrium. (D) Graft is folded. (E) Fold of the graft completed. (F) Caudal end graft with guide sutures in its final position. (From the Mayo Foundation, with permission.) and connected by guide sutures. In three patients (patients 1, 3, ad 18), conchal grafts from both auricles were harvested to fill a large saddle, including the bony dorsum. After closure of the skin incisions, petroleum jelly (Vaseline) gauze coated with antibiotic ointment was used as internal dressings for 3 to 5 days, depending on the patient’s age and the extent of the dissection. Each patient received amoxicillin with clavulanic acid perorally for 5 days postoperatively. Laryngoscope 114: April 2004 Follow-Up Clinical follow-up included a questionnaire to evaluate the patient’s functional and aesthetic self-estimation (five-point box scale, with satisfaction graded as 0 ⫽ no, 1 ⫽ poor, 2 ⫽ moderate, 3 ⫽ good, and 4 ⫽ very good) and visual analogue scales (from 0 –10) about nasal passage, olfaction, and general satisfaction after the operation. Furthermore, allergy, pain, epistaxis, nasal Pirsig et al.: Nasal Septum Reconstruction 629 crusting, and dryness of the nasal mucosa were recorded preoperatively and postoperatively. The rhinoscopic, endoscopic, and palpable findings of the nose and auricle were documented, particularly the mobility, projection, and protection of the nasal lobule; the contour of the nasal dorsum; and the shape and scar of the donor auricle. Standardized photographs were made of the nose and auricle preoperatively and at follow-up and were evaluated by two investigators for nasal shape, saddling of the nasal dorsum, and projection of the lobule. Complete preoperative and postoperative rhinomanometric data according to the Standard Committee17 and olfactometric data (Sniffin’ Sticks olfactory function test, Erlangen, Germany) were available for 12 patients. These tests were not performed in 11 patients because of septal perforation, and the data were incomplete for 3 other patients. RESULTS Nose The 26 patients were examined postoperatively after a mean period of 36.7 ⫾ 22.3 months. Each patient had a mean number of previous nasal operations of 1.6. A submucous septal resection (Killian) had been performed previously in 17 patients (65%), and 11 patients (42.3%) had a septal perforation (Table I). At the Otorhinolaryngology Clinic, University of Ulm, 2 patients (patients 11 and 21) had primary rhinoplasty and 24 had a revision rhinoplasty (by an external approach in 3 [patients 2, 9, and 21]). The same surgeon performed surgery on 23 of the 26 patients. Postoperatively, all wounds healed by primary intention. Six months after surgery, one patient developed a 2-mm septal perforation in Cottle area III. He previously had had rhinoplasty with submucous septal resection. At followup, nasal appearance had improved (by subjective scoring) in 24 patients (92.3%) and was nearly the same in 2 (patients 12 and 23) Table I). On a five-point box scale of 0 to 4, the patients scored their satisfaction with functional and aesthetic result as 3.2 ⫾ 0.79 (with a score of 4 representing “very good”) (Table I). The evaluation of the preoperative and postoperative nasal appearance by the patients was almost identical to that by the physicians except in three cases. In two of these cases, the physician’s evaluation was lower (less satisfied) than the patients’. In the third case, the male patient scored the postoperative result lower (less satisfied) than did the two physicians. The mean score on a visual analogue scale of 0 to 10 for postoperative nasal breathing was 7.3 ⫾ 1.87 (range, 3–10), and the mean score for postoperative olfaction was 8.19 ⫾ 1.69 (range, 4 –10) (Table I). In three patients (patients 12, 17, and 23) a unilateral nasal valve stenosis reduced nasal breathing; this was substantiated by active anterior rhinomanometric findings. The frequency of preoperative and postoperative complaints such as pain, epistaxis, nasal crusting, and feeling of dry nose is listed in Table II. The large number of complaints can be explained by nasal mucosal atrophy caused by previous nasal injury and radical operations. Many of the complaints were associated with epistaxis and nasal septal perforation (Table II). According to the evaluation of the examiners and the patients’ medical records and photographs, the nasal apLaryngoscope 114: April 2004 630 TABLE II. Frequency of Preoperative and Postoperative Complaints of 26 Patients Who Had Reconstruction of Anterior Nasal Septum by Back-to-Back Autogenous Ear Cartilage Graft. Preoperative Postoperative Complaint No. of Patients No. of Patients With Septal Perforation No. of Patients No. of Patients With Septal Perforation Pain Epistaxis Crusts Dry nose 5 8 17 19 2 7 9 8 1 5 11 18 1 4 5 7 pearance improved in all patients. No transplant had been rejected or displaced, and all the grafts for the anterior septum had remained straight, with no curling, bending, or warping. At follow-up, the preoperatively empty columella was partially filled by the graft in all patients. In profile view, the columella appeared normal in 21 patients (81%) and retracted in 5 (19%). Of these five patients, only one patient had a septal perforation. Projection of the nasal lobule was deemed good in all patients. The auricular cartilage grafts under the dorsum also maintained their position and showed no signs of resorption. Depending on the thickness of the dorsal skin, the shape of the dorsal grafts showed irregularities of the surface in three patients (11.5%). The preoperative saddle deformity was completely corrected in 17 patients (65.4%) (Figs. 2–5). The saddle deformity was minimally visible in six patients (23.1%) (Figs. 6 and 7) and slightly present, but less so than before surgery, in 3 (11.5%) (Fig. 8). No additional alterations of the dorsal skin, including color, pattern of vessels, and pigmentation, were noted at followup. Pain was not elicited with palpation of the grafted area. In two patients, a septal perforation was closed successfully by a multiple-pedicled advancement flap technique18 in the same stage. In another nine patients, surgical closure of the perforation was not attempted (six patients refused the procedure, and the perforation was too large in three patients). Auricle Complications at the harvest site in the auricle generally were minimal. An aural seroma developed postoperatively in one patient and resolved after aspiration. One wound dehiscence healed after repeat suturing, and one minor skin infection was treated with antibiotic ointment. During the first postoperative weeks, two patients complained of pain when lying on the operated auricle. At subsequent follow-up, no patient complained of pain or cosmetic changes of the operated auricle. However, one male patient thought that the ear was more “sensitive” in cold weather. The graft donor site did not show any visible alteration in shape, size, or position. The scar was essentially invisible in 9 patients and minimally visible as a small white line in the other 17 patients. As expected, the cartilaginous defect was palpable in all patients. One woman complained of a visible, malodorous production of Pirsig et al.: Nasal Septum Reconstruction Fig. 2. Patient 19 with completely corrected saddle nose, with septal perforation not corrected. Appearance (A–C) before and (D–F) 18 months after surgery. sebum behind the operated auricle, but this could not be confirmed on examination. DISCUSSION The method described in the present report of harvesting a back-to-back cartilage graft (2.5–3.0 cm long) from the auricle and transplanting it into the recipient bed of the columella and anterior septum enables longlasting reconstruction of a deficient caudal septum. The long-term results of our patients clearly indicate that macroscopically the grafts remain intact and sufficiently large, straight, and stable to create an adequately proLaryngoscope 114: April 2004 jected nasal lobule with physiological mobility and to improve nasal breathing. The results of our study support the contention that conchal cartilage with the perichondrium attached bilaterally is an ideal autogenous graft because it can remain viable without resorption. In a series of more than 2000 autogenous cartilage grafts performed over a 17-year period, Tardy et al.14 did not detect the loss of any graft because of early infection or host rejection. Because of the network of elastic fibers within its matrix, ear cartilage can withstand considerable bending force without fracturing. It is available in sufficient amount (up to 2.5 ⫻ 3.5 cm Pirsig et al.: Nasal Septum Reconstruction 631 Fig. 3. Patient 20 with completely corrected saddle nose, with septal perforation not corrected. Appearance (A and B) before and (C and D) 28 months after surgery. per concha) and is easily harvested without complications at the donor site. Its curved surface, flexibility, thinness, and capacity for minimal distortion make it ideal for functional and aesthetic nasal surgery.1,11,14 Tardy et al.14 noted that care is required in harvesting and handling conchal cartilage grafts in patients older than 50 years of age because the grafts are usually brittle and vulnerable to trauma. We Laryngoscope 114: April 2004 632 confirmed this observation in 8 of our 26 patients who were 50 years of age or older. Sheen11 recommended conchal cartilage grafts for nasal reconstruction when septal cartilage is unavailable. He recreated both dorsal contour and tip grafts. He totally resected the concha, with the anterior surface devoid of perichondrium and with the perichondrium attached to the posterior surface. Pirsig et al.: Nasal Septum Reconstruction Fig. 4. Patient 21 with completely corrected saddle nose. Appearance (A–C) before and (D–F) and 28 months after surgery. In 14 patients, Petruson9 reconstructed the anterior nasal septum with a cartilage graft from the superior part of the auricle with the perichondrium attached on both sides. By cutting partly through the perichondrium and cartilage on the concave side of the graft, he attempted to obtain a graft with a flat surface. Although none of his patients had resorption of the cartilage, a few had postoperative curling of the grafts. Two objections to the use of conchal cartilage to reconstruct the anterior septum are its curved surface and insufficient size. With the technique we describe, these objections are met by not separating the two curved surfaces but by cutting cartilage and not perichondrium and Laryngoscope 114: April 2004 by bending and creating a back-to-back graft that heals more quickly because of the connecting perichondrium layer. A straight 2.5- to 3.0-cm graft is obtained with this technique. Removing the perichondrium from one or both surfaces increases the incidence of graft curling. To overcome the tendency to warp, various techniques have been used to release the inherent resilience, including the use of multiple cross-hatching incisions or gentle morselization,14 placement of figure-of-eight suture in the convex side, or suturing together two separated curved conchal cartilages.1 Endo et al.3 made numerous transverse parallel incisions on the “superficial side” of the ear cartilage to release tension. This corrected the wave and made the Pirsig et al.: Nasal Septum Reconstruction 633 Fig. 5. Patient 26 with completely corrected saddle nose, with septal perforation not corrected. Appearance (A–C) before and (D–F) 32 months after surgery. cartilage straight. Then they inserted two to four stacked cartilages over the dorsum to correct the saddle deformity. None of the grafts were rejected, but graft resorption occurred occasionally when more than four pieces of ear cartilage were used. After 14 years of experience of performing the operation in more than 1200 patients, Endo et al.3 considered ear cartilage superior material for augmentation rhinoplasty in Japanese patients. Sheen12 observed that conchal cartilage survives better than any other autogenous material in scarred and vascular-deficient sites. This was true also for all of our Laryngoscope 114: April 2004 634 patients. Our back-to-back graft is different from the typical shorter columella strut, which is sutured between the full length of the medial crura to reinforce tip support. By placing the back-to-back conchal cartilage graft obliquely between the anterior nasal spine and the point where the caudal borders of the upper lateral cartilage meet the quadrangular cartilage, we are attempting to replace the anatomical position of the anterior septum. The graft is anchored between the feet of the medial crura, but it leaves the cranial halves of the medial crura free, as they normally are anatomically. This slightly oblique position Pirsig et al.: Nasal Septum Reconstruction Fig. 6. Patient 25 with minimally visible remaining saddle nose, with septal perforation not corrected. Appearance (A–C) before and (D–F) and 37 months after surgery. of the graft helps to prevent broadening of the columella. At the uppermost end, the graft is sutured to the upper lateral cartilage, and care should be taken to avoid narrowing the angle of the valve with a graft. In three of our patients (11.5%), the graft did narrow the angle and reduced breathing. In our series, the rate of permanent minor complications at the recipient site was 15.4% (three patients with narrowing of the angle of the valve and one patient with a 2-mm septal perforation). There were no major complications. Although reconstruction of the anterior septum was successful in all 26 patients, complete correction of the Laryngoscope 114: April 2004 saddle was achieved in only 17 (65.4%). Of the other nine patients, improvement of the dorsal contour was observed in seven at follow-up. Except for three patients, the correlation between the examiners and the patients of the evaluation of the aesthetic result was high. The main problem with the transplanted piece(s) of the conchal cartilage was the irregularities of the dorsum. These irregularities were more prominent in patients who had scarred, thin skin. In particular, it can be difficult to bridge the tiny gap between the nasal bones and the cymba graft. Sheen12 pointed to this “visibility at one end or the other” as the most frequent complication of conchal grafts and Pirsig et al.: Nasal Septum Reconstruction 635 Fig. 7. Patient 7 with minimally visible remaining saddle nose. Appearance (A–C) before and (D–F) and 65 months after surgery. suggested trimming or crushing the edges of the graft to overcome this disadvantage. The use of a layer of perichondrium (one patient) or lyophilized dura mater (two patients) on top of the conchal graft proved effective in straightening the nasal dorsal contour in our three patients. Clearly, the grafting technique we describe cannot restore mucosal function, especially in patients with septal perforation. It was possible to eliminate intranasal pain in four patients, crusting in six, and recurrent epistaxis in three. However, crusting remained in 11 patients and epistaxis in 5, and a dry nose (sicca syndrome) was present in 18 of 19 patients postoperatively. Most of these complaints were related to a previously existing septal perforation Laryngoscope 114: April 2004 636 caused by previous trauma (surgical or nonsurgical). Nevertheless, nasal breathing improved in 9 of these 11 patients because the valve area had been restored by the graft. The technique of harvesting conchal cartilage for grafting through an anterolateral approach was adopted from Brent.16 Our results confirm Brent’s findings that anterolateral incisions do not produce an objectionable scar. Of 29 donor sites in all, temporary minor complications occurred in only 3 (10.3%). Karen et al.19 reported a 22% rate of permanent complications at the donor site of 18 auricles. These complications were essentially notches where auricular composite grafts were harvested to repair nasal vestibular stenosis. The mean follow-up for these cases was 3.5 years. Pirsig et al.: Nasal Septum Reconstruction Fig. 8. Patient 4 with slightly remaining saddle nose, with septal perforation not corrected. Appearance (A–C) before and (D–F) and 75 months after surgery. CONCLUSION A back-to-back conchal cartilage graft method used to reconstruct the anterior septum and associated saddle nose deformity in patients with severely deficient (destroyed) septum attributable to trauma (surgical or nonsurgical) has proved to be a reliable and safe technique in 26 patients. In addition to providing satisfying functional relief (breathing), the aesthetic results were gratifying in 65% of the patients. No macroscopic resorption or warping occurred. The graft was viable, straight, and stable and provided physiological mobility and projection of the nasal lobule. The technique can be performed in one stage with Laryngoscope 114: April 2004 the use of local or general anesthesia and is easy to teach. It left no permanent complications at the donor auricle and showed minor functional insufficiency at the recipient site in 11.5% of the patients. The primary indication for using the back-to-back conchal cartilage graft is replacement of the caudal septum when the majority of the septal skeleton (cartilage and bone) has been destroyed by trauma (surgical or nonsurgical). If a patient has enough septal cartilage or bone remaining, a caudal-end reconstruction could be accomplished with transplanted autogenous septal cartilage or bone.13 With this novel back-to-back autogenous conchal Pirsig et al.: Nasal Septum Reconstruction 637 cartilage graft, use of ribs, iliac crest, calvarial bone, or other more invasive graft techniques for tissue harvest are obviated. In addition, reconstructing the caudal septum with the back-to-back conchal cartilage graft and careful suturing of the graft to the upper lateral cartilage allow reconstitution of the nasal valves; thus, there is no need for spreader grafts, “resuspension,” and alar battens. Because dorsal depression persisted in 35% of patients, perhaps because of partial cartilage resorption, additional soft tissue grafting should be considered during the primary operation. If required, a secondary procedure to insert additional grafts to improve the dorsal contour is always a viable option and has minimal associated morbidity. 8. 9. 10. 11. 12. 13. BIBLIOGRAPHY 1. Arden RL, Crumley RL. Cartilage grafts in open rhinoplasty. Facial Plast Surg 1993;9:285–294. 2. Drumheller GH. Septal reconstruction in the deficient nose. Rhinology 1976;14:189 –192. 3. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty: observations on 1200 cases. Plast Reconstr Surg 1991;87: 54 –59. 4. Gammert C, Masing H. 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